Winona State University College of Nursing & Health Sciences

Department of Health, Exercise, & Rehabilitative Sciences

Internship Handbook

Cardiopulmonary Rehabilitation

Exercise Science

Public Health

Spring 2015

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Internships provide students the opportunity to develop career interests and skills in professional settings. This handbook provides an overview of the internship process.

TABLE OF CONTENTS PAGE

Introduction/Purpose ............................................................................................... 2 HERS Department Contacts ...................................................................................... 2 Internship Checklist................................................................................................... 3 Internship Process Objectives ............................................................................................................. 4 Prerequisites ......................................................................................................... 4 Appeals Process .................................................................................................... 4 Planning ................................................................................................................ 4 Advising ................................................................................................................ 4 Qualifying Internship ............................................................................................ 4 Interview............................................................................................................... 5 Credits/Work Hours .............................................................................................. 5 Contract (Memorandum of Agreement) .............................................................. 5 Registration .......................................................................................................... 5 Responsibilities Student Intern’s Responsibilities .......................................................................... 5 Student Professional Liability Insurance .............................................................. 6 Student Health Insurance ..................................................................................... 6 HERS Faculty Internship Advisor’s Responsibilities .............................................. 6 HERS Administrative Assistant’s Responsibilities ................................................. 6

Internship Search Tips .............................................................................................. 7 Intent to Internship Form ......................................................................................... 8 Sample Student’s Internship Cover Letter ................................................................ 9 Sample Resume ....................................................................................................... 10 ADDITIONAL FORMS: Important Notices ................................................................................................... 12 Minnesota Background Study Form ....................................................................... 13 Authorization for Release of Student Background Study Form .............................. 14 Wisconsin Background Information Disclosure Instructions .................................. 15 Wisconsin Background Information Disclosure ...................................................... 16 Health Information and Requirements Forms ........................................................ 18 Hepatitis B Vaccine Declination .............................................................................. 19 CPR/AED and First Aid Certifications ...................................................................... 20 Reduced Student Fee Authorization ....................................................................... 21 Weekly Work Log & Reflective Journal Format ...................................................... 22 Student Evaluation of Internship Supervisor and Site ............................................ 23 Internship Program Evaluations of Student Intern: Cardiopulmonary Rehabilitation Mid-point Evaluation ..................................... 24 Cardiopulmonary Rehabilitation Final Evaluation .............................................. 25 Exercise Science Mid-point Evaluation ............................................................... 26 Exercise Science Final Evaluation ....................................................................... 27 Public Health Mid-point and Final Evaluation .................................................... 28

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INTRODUCTION/PURPOSE The Health, Exercise & Rehabilitative Sciences (HERS) Internship Program provides significant experiential learning opportunities valuable to a student’s professional development. The field experience provides a means of reinforcing and enhancing academic preparation, while interns actively apply knowledge and skills in a real work environment. Through cooperative planning and implementation in partnership with the internship agency (site), the Department requires the following internships of eligible degree candidates: HERS 496 Public Health 10 credits HERS 497 Cardiopulmonary Rehabilitation 8 credits HERS 499 Exercise Science 8 credits All HERS Department internships are offered for up to 12 credit hours. See Credit/Work Hours section, page 5, for details.

This handbook has been designed to assist Cardiopulmonary Rehabilitation, Exercise Science and Public Health majors in the procedural aspects involved in successful acquisition and completion of the “capstone” internship experience. The internship experience serves as a practical vehicle of transition for students to make the change from classroom to work place settings. With the structured environment of a University approved agency/site and under the direct supervision of a university approved professional in the field, the student receives guidance in transitioning from the academic setting to the role of an employee in a “real life” worksite.

HERS DEPARTMENT CONTACTS:

Dr. Gary Kastello, Professor, Chairperson Telephone: 507.457.5219 (800.242.8978) E-mail: gkastello@winona.edu Fax: 507.457.2554

Mary Kaye Pecarina, Administrative Assistant Telephone: 507.457.2600 (800.242.8978) E-mail: mkpecarina@winona.edu Fax: 507.457.2554

Cardiopulmonary Rehabilitation Faculty Internship Advisor: Dr. Teresa E. Lee Telephone: 507.457.2271 (800.242.8978) E-mail: telee@winona.edu Fax: 507.457.2554

Community Health Faculty Internship Advisor: Dr. Peter Sternberg Telephone: 507.457.5693 (800.242.8978) E-mail: psternberg@winona.edu Fax: 507.457.2554

Exercise Science Faculty Internship Advisors: Dr. Phil Appicelli Telephone: 507.457.5388 (800.242.8978) E-mail: pappicelli@winona.edu Fax: 507.457.2554

Dr. Erin White Telephone: 507.457.2577 (800.242.8978) E-mail: ewhite@winona.edu Fax: 507.457.2554

Internship Handbook: HERS website: http://www.winona.edu/hers or the HERS SharePoint: https://mywsu.winona.edu/departments/he/default.aspx

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INTERNSHIP CHECKLIST

1. Review the Internship Handbook located on the HERS website http://www.winona.edu/hers or SharePoint site https://mywsu.winona.edu/departments/hers/default.aspx. Read thoroughly before proceeding. Attend all mandatory internship meetings.

2. Meet with Faculty Internship Advisor about possible internship sites and determine student’s eligibility. � Review DARS Report � All major courses completed with grade of “C” or better and student meets 2.50 minimum GPA

(Cardiopulmonary Rehabilitation requires 2.8 minimum major GPA) � Bring and review résumé and cover letter. (Additional assistance is available from the Warrior Success

Center 314 Maxwell Hall.) A database of past internship sites is on the HERS SharePoint https://mywsu.winona.edu/departments/hers/

3. Contact possible internship sites and ask about: � Types of internships available � Application procedures � Obtain copy of intern’s duties and responsibilities � Obtain credentials and experience of internship site supervisor for potential site (example: supervisor’s

business card)

4. Meet again with Faculty Internship Advisor to discuss duties/responsibilities and credentials (per 3. above) and complete “Intent to Internship” form (page 8) with 2-3 site choices. This should be done at least 10 weeks prior to start of Internship. Submit “Intent to Internship” form to HERS Administrative Assistant.

5. Special Circumstance Appeal Student may file an appeal to the Department Chair if student and faculty advisor agree upon circumstances. (see page 4)

6. Meet with HERS Department Administrative Assistant for additional information and to complete all forms. � Important Notices � Student Background Study Forms: Students are financially responsible for background studies that meet

both WSU and the internship site’s requirements � Reduced Student Activity Fee Authorization (if site is more than 50 miles away from Winona) � Health Information and Requirements for Internship Program

o Proof of Medical Insurance o Dates of Mantoux (Tuberculosis) Test and all Immunizations. o CPR/AED and First Aid Certification Requirements (See Page 22)

7. HERS Department will e-mail affiliate agreement with cover letter to potential sites.

8. Once affiliate agreement is fully executed and all WSU requirements are met, obtain permission override to register for course. (Consider: Financial Aid, scholarships, personal insurance).

9. Intern reminders: � Submit logs, journals and other materials to Faculty Internship Advisor as directed � Follow up with site supervisor on timely filing of midpoint and final evaluation forms

10. Submit the Student Evaluation of Internship Supervisor and Site to Faculty Internship Advisor at end of

internship. PowerPoint presentation is required of Public Health Majors. All paperwork will be reviewed for completion.

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INTERNSHIP PROCESS Objectives The capstone internship experience affords student interns opportunities to: � Participate in productive work activities as cooperative, contributing team members. � Actively apply previously acquired knowledge and technological skills to meeting site/agency job

requirements and expectations � Demonstrate interpersonal relations and communication skills as applied to on-the-job oral and written

communications � Exercise decision-making and problem-solving abilities in performing self-directed work assignments � Evaluate current expertise and academic achievements in relation to agency/site needs and performance

standards � Assess career plans and aspirations in relation to field experience Prerequisites � A minimum major GPA of 2.5 or better. (Cardiopulmonary Rehabilitation requires 2.8 minimum major GPA) � Completion of all major coursework

Special Circumstance Appeal Process Students may consider filing an appeal for the right to intern by following the procedure below: If students have not completed all major coursework prior to the start of the intended internship, they must file a written appeal with the HERS Department. An application for appeal form is available from the HERS SharePoint site. Appeals will be reviewed by the HERS Department Chair and then by the HERS curriculum committee. The appeal process will take at least one month. Please note that a student may not begin his/her internship without departmental approval. The curriculum committee will make recommendations based upon the following documents provided by the student:

� Student must explain his/her extraordinary circumstances � Letter from the student’s major advisor supporting an early internship and the student’s abilities � Copy of student’s academic record

Appeals should not be requested frivolously. An internship appeal represents a procedural safeguard for the student. Decisions made by the curriculum committee are final. Planning The application procedures for some intern sites recommend more than a semester’s notice. Therefore, begin planning early. Carefully read all forms, procedures and requirements. Advising Meet with your Faculty internship advisor to: � discuss internship requirements � discuss the search process for securing your internship

Qualifying Internship � Since securing the internship experience is essentially the same as finding a professional position, you

should use appropriate job search procedures to locate a qualifying internship experience. � You are responsible for establishing and verifying the quality of your internship position. For a meaningful

experience, qualifying positions must meet the following guidelines: o Interns should report to an on-site internship supervisor who is an experienced management/

supervisory-level employee

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o Work experience must involve a challenging variety of responsibilities rather than repetitive, routine tasks in order to be a quality experience. Positions comparable to file clerk, record-keeper, or purely clerical in nature do not qualify

o Special work assignments delegated to the HERS student intern may include special projects, administrative management and/or supervisory responsibilities consistent with the intern's academic preparation and background

� If you have a double option within your major, each with an internship requirement, two distinct internships are required. This may be done at the same agency or different agencies but you must follow and complete all requirements such as hours, evaluations, summaries in a distinctly individual manner.

� Some internship sites provide a salary or stipend with the internship. This is acceptable as long as the internship meets the objectives of the HERS Department and is approved by the Faculty Internship Advisor.

� Internships involving a student's relatives in any capacity normally are not approved because of the potential conflict of interest.

Interview � Arrange a face-to-face or phone interview with appropriate site/agency personnel to discuss all pertinent

internship information and forms. Be sure to discuss such topics as the nature of your academic preparation in your subject discipline, criteria for qualifying for internship positions, detailed job description, monetary compensation, site supervisor's verification on reports and any other details necessary for a mutual understanding of internship requirements, conditions and standards.

Credits/Work Hours � All internships are taken on a pass/no credit basis. � The number of hours required for each internship varies based upon program standards for each subject

discipline. Generally one semester (15 weeks) or equivalent is set aside to complete the internship with a total of 600 hours required.

� Students must work a minimum of 20 hours/week and no more than 45 hours/week. Fewer than 40 hours in any one week will necessitate additional weeks at the internship site. A student may not decrease the required consecutive internship weeks by consistently working more than 40 hours per week. Conversely, students working less than 40 hours per week must complete all internship requirements within 20 weeks, unless prior approval has been granted by the Faculty Internship Advisor.

� Students must begin and complete at least one-half (1/2) of the required hours during the semester in which registered.

� Students may enroll in a maximum of 18 credit hours per semester; however, the internship is a full-time commitment and this is strongly discouraged.

� Students in the HERS Department may complete only one internship per semester. Contract – Memorandum of Agreement After meeting with the appropriate Faculty Internship Advisor and at least 10 weeks prior to the start of the internship, the student intern must submit completed Intent to Internship form to the HERS Administrative Assistant. Upon receipt, the HERS Administrative Assistant will e-mail a Memorandum of Agreement and cover letter to potential sites. Registration Once the student intern completes all required documentation, has received confirmation from the internship site, and a fully executed Memorandum of Agreement is in place, the student intern should obtain a permission override from the HERS Administrative Assistant in order to register. Student Intern’s Responsibilities � Successfully complete the total work hours and job requirements as agreed upon with the on-site internship

supervisor/site/agency and the Faculty Internship Advisor. � Complete an Internship Log/Work Report and Journal for each week of the internship and review with the

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on-site supervisor. Submit these as directed to the HERS Faculty Internship Advisor. Retain a copy for your own future use. Observe the usual standards for effective written communications.

� Complete and submit the Site/Supervisor Evaluation forms to the HERS Faculty Internship Advisor. (page 25) � For Community Health/Public Health Interns – prepare a 15-minute illustrated (with photographs, etc.)

PowerPoint presentation about your internship and either e-mail it as an attachment to the Faculty Internship Advisor OR set up a date to give your presentation in person to students in these majors.

(NOTE: In order to receive a final grade, all of the above must be satisfactorily completed and submitted to the HERS Faculty Internship Advisor within two weeks of completion of internship.) Student Professional Liability Insurance All WSU students enrolled in internships and/or practicum must purchase professional liability insurance. It is an industry standard that any individual involved with the wellbeing of another must carry malpractice insurance. Therefore, Minnesota State Colleges and Universities (MnSCU) provides a blanket liability insurance policy with American Casualty Company ($2 million per occurrence; $5 million aggregate) at a cost of $13.00 per academic year. Student Health Insurance All WSU students enrolled in internships must possess health insurance; some internship sites may require verification of coverage. HERS Faculty Internship Advisor’s Responsibilities � Meet with student interns. � Approve eligibility of student. � Review resume and cover letter. � Approve internship site, supervisor and duties/responsibilities and Intent to Internship form. � Receive and review daily/weekly intern logs & journals. � Receive and review midpoint and final evaluations. � Ensure that Intern Evaluation Forms (midpoint and final) are completed by the on-site supervisor and reviewed with student intern. � Contact the site supervisor as necessary. � Receive and review Site/Supervisor Evaluation form. � Exit interview with the student intern. � Assign final grade. HERS Administrative Assistant’s Responsibilities � Keep handbook and forms current on SharePoint site � Receive the Intent to Internship form from the student intern and start file � Start the Affiliate Agreement Process � Meet with the student intern to complete forms:

o Important Notices o Student Background Study/Studies, as required by WSU and Internship Site o Reduced Student Activity Fee (if applicable) o Collect Health Information & any other Requirements

� Explain MnSCU liability insurance to the student intern � Track the Memorandum of Agreement and obtain appropriate signatures � Process permission override in order for student to enroll in the internship. � Send midpoint and final evaluations to site and identify Faculty Internship Advisor � Give student intern’s file to appropriate Faculty Internship Advisor � Route forms to appropriate Faculty Internship Advisor as necessary

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INTERNSHIP SEARCH TIPS

1. View the internship search process as a learning experience that will provide insights into your future job

searches. The HERS Department considers it the responsibility of prospective interns to locate their own internship sites. The Department provides a list of previous internships and national organizations publish site locations and directories to assist the search.

2. The Internet is an excellent source, in particular sites at the National Wellness Institute and ACSM. Also

Directory Guides from national organizations can lead the student to specific internship sites at a wide range of geographical locations.

3. After compiling a list of possible sites that interest you, meet with your HERS Faculty Internship Advisor to

discuss them. 4. Internship applications will usually proceed in one of two ways. If time permits, a cover letter and resume

should be sent to the potential internship sites. Tips for sample cover letter and resume are available in this packet. This may then be followed up with a phone contact. If time is limited, direct telephoning may be your initial contact with the internship site. At all times during the search process, it is important to project a professional image.

5. Always remember to keep in touch with your HERS Faculty Internship Advisor during the search process.

Your internship advisor may have information about potential internship sites and can provide coaching with cover letters, résumés, interviewing techniques, etc.

6. When you have a site that has agreed to accept you as an intern, verify that it meets the HERS site

qualifications including: focus on subject area, professional in nature, new learning experience and on-site supervisor availability.

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DEPARTMENT OF HEALTH, EXERCISE, & REHABILITATIVE SCIENCES Intent to Internship

Name: _____________________________________________________ Date: ______

Local Address: ________________________________________________ Phone: _________________________

Permanent Address: __________________________________________________________________________

Tech ID#___________________ WSU Email:_______________________________________________________

Other Email: __________________________________________Major/Option: ___________________________

Provide DARS Number of Credits Sought: ________ Faculty Internship Advisor: _________________________

# of Credits obtained prior to Internship:_________ ALL HERS Courses Completed: Y / N GPA:__________

*First Choice-- Internship Site:__________________________________________________________________

Address:____________________________________________________________________________________

On-Site Supervisor: _________________________________________ Title:_____________________________

Email:_______________________________________________ Phone:_________________________________

Supervisor Credentials checked: _______ Duties/Responsibilities (attached) approved by advisor: ____________

Internship Start Date: _________________End Date: _________________OR Semester:____________________

**Second Choice-- Internship Site:_______________________________________________________________

Address:____________________________________________________________________________________

On-Site Supervisor: _________________________________________ Title:_____________________________

Email:_______________________________________________ Phone:_________________________________

Supervisor Credentials checked: _______ Duties/Responsibilities (attached) approved by advisor: ____________

Internship Start Date: _________________End Date: _________________OR Semester:____________________

***Third Choice—Internship Site:________________________________________________________________

Address:____________________________________________________________________________________

On-Site Supervisor: _________________________________________ Title:_____________________________

Email:_______________________________________________ Phone:_________________________________

Supervisor Credentials checked: _______ Duties/Responsibilities (attached) approved by advisor: ____________

Internship Start Date: _________________End Date: _________________OR Semester:____________________

Student Signature: ____________________________________________________Date:___________________ Faculty Internship Advisor Signature: ____________________________________________________Date:___________________

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SAMPLE STUDENT’S INTERNSHIP COVER LETTER (DATE) (ADDRESS) Dear ( ): I am currently a (senior) at Winona State University majoring in Exercise & Rehabilitative Sciences: Exercise Science. As a part of my academic program, I am required to complete an internship, which will allow me to utilize the skills I am developing in my coursework. I would like to do this internship with (name of agency). To date, I have completed coursework in (______________________) as well as (____________________). My minor in (____________________) further enhances my (_____________________) degree by giving my (___________________) program a direct focus on (______________). I have earned a (3.5) grade point average on a 4.0 scale. As a part of my internship contract, I would need to work a minimum of 600 hours for your organization between (_____________and______________). This time can be changed to fit any special projects you might be working on which I might be of assistance. During the time period, I will (have no other obligations/list any other obligations). If you are willing to consider the possibility of sponsoring an intern, please contact me, and I will forward letters of recommendation and a transcript of my coursework. At that time, I could also set up an appointment to talk with you further about my qualifications. I have enclosed a resume for your review. I look forward to the possibility of interning with your organization and hope to hear from you in the near future. Sincerely, (Name) (Address) (Phone Number) (E-mail Address)

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Jane Smith Current Address: Permanent Address: 123 Winona Street 321 Main Street Winona, MN 55987 Any town, MN 55123 (507) 450-1111 (507) 444-2222

jsmith@winona.edu CAREER OBJECTIVE

An internship promoting healthy lifestyles

EDUCATION & TRAINING

Winona State University, Winona, MN B.S. in Public Health (Community Health Option), Communication Minor Expected Graduation: Fall, 2010 GPA: 3.48/4.0

RELEVANT COURSEWORK

Nutrition Personal & Community Health Health Perspectives School & Community Health Public Health Health Promotion Skills

Epidemiology Health Promotion Skills Grant Writing Behavioral Interventions Program Planning in Health Promotion

RELATED EXPERIENCE • Health Behavior Assessment of Rochester Community Technical College and Winona State

University Project o Established and distributed a Health Needs Assessment Survey to students through

Survey Monkey o Developed and distributed Health Needs Assessment Survey to students o Maintained and analyzed survey responses using Zoomerang survey database program o Successfully awarded a University Foundation Grant o Made recommendations to WSU Health Educator based on survey findings

• Grant Writing o Wrote an extensive grant proposal for non-profit organization

• Campaign for Safer Drinking Standards for students at Winona State University; designed poster, pamphlet, and website

• WSU Binge Drinking and First Year Students Investigation, Community Health Course o Researched and implemented several research methods related to college drinking

“norms” Obtained data from comprehensive needs assessment Created and distributed personal interest surveys Conducted personal interviews Conducted and led focus groups

• Middle School Health Experience o Worked with local Middle School health teacher to develop a student led Health Fair o Assisted students with research of health topics and displays for school Health Fair

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OTHER EXPERIENCE

• Any town Park District, Any town, MN o Camp Counselor: 5/2008 – present

Safety: Promoted safe environment, counseled healthy living for children Responsibility: Created daily agendas, supervised children at all time

• Any town Fitness Center, Any town, MN o Swim Instructor, Lifeguard: 5/2008-6/2009

Customer Service: Communicated with colleagues, patrons, and children Leadership: Supervised swim lessons and enforced rules to patrons Safety: Maintained safe environment for adults and children

SKILLS AND CERTIFICATIONS

• Adult, Child and Infant CPR, American Red Cross • AED Essentials, American Red Cross • Disease Prevention, American Red Cross • Experience with Computers: Proficient with Windows, Office packages (Word, PowerPoint,

Excel, Access), data processing packages (Epi Info, SPSS), and computer design packages( Adobe Photoshop and InDesign)

COMMUNITY SERVICE

• Breast Cancer Fundraiser, 2009: Helped organize and run fundraiser • Winona Middle School, 2009, 2008: Helped 6th grade health class organize a health fair • Flood Disaster Relief, 2007: Minnesota City, Spent time helping families rebuild their homes • Winona Food Drive, 2007: Worked with community for two weeks collecting canned food • Adopt-A-Family, 2009, 2007: Adopted numerous families and provided them with gifts for the

holidays

EXTRA-CURRICULAR ACTIVITIES

• Women’s Health Issues Club: Assistant Vice President, 2008 - present • H.O.P.E (Health Organization for Promotion and Education): 2008 - present • College Intramural Team: Soccer, 2008

AWARDS AND HONORS

• Dean’s List: Winona State University, 2014 • Etiquette Dinner: Winona State University, 2013 • Honor Student: Winona State University, 2013

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MINNESOTA STATE COLLEGES AND UNIVERSITIES WINONA STATE UNIVERSITY

HEALTH, EXERCISE & REHABILITATIVE SCIENCES

IMPORTANT NOTICES

REASONABLE ACCOMMODATIONS

There are conditions for which accommodations may be appropriate under the Americans with Disabilities Act. The Health, Exercise & Rehabilitative Sciences Department will make all reasonable accommodations required by law for otherwise qualified individuals. To receive accommodations, you must contact the Office of Disability Services, located in Maxwell 313. The telephone number is 507.457.5878. RESPONSIBILITY FOR HEALTH CARE COSTS Any health care costs incurred during the period of time you are a student in the Health, Exercise & Rehabilitation Programs will be your responsibility. Students enrolled in a Winona State University HERS program are required to have proof of health insurance. WORKERS’ COMPENSATION It is the position of the internship site/facility and the College/University that, as a WSU student intern, you are not an employee of either the site or the College/University for purposes of Workers’ Compensation insurance. (However, if you are officially employed by the site, you would follow the site’s workers’ compensation policy.) BACKGROUND CHECKS An integral part of the HERS Program is the experiential education opportunities. To provide this experience, the College/University contracts with organizations outside of the University. State law requires that any person who provides services which involve direct contact with community members or others outside the University have a background study conducted by the State. A site may initiate a background study by asking you to complete a form so that a background check can be conducted. If, as a result of the background study, you are disqualified from direct contact, it is highly unlikely that the site will be able to allow you to participate in its internship program. If you refuse to cooperate in the background check, the facility will refuse to allow you the internship opportunity. The HERS Program does not guarantee an alternative site placement. DATA PRACTICES ADVISORY AND INFORMED CONSENT Some facilities also impose certain requirements regarding the health of persons working in their facilities and may require that health information about students in internship programs be made available to them. The College/University may ask you to provide health information which will be used to determine whether you meet an internship site’s health requirements for care providers. Health information collected is private data on you. A site may refuse to allow you to participate based on data provided by you. The information provided will be disclosed, as needed, to the Department of HERS and, should any site request the data, to any site where you are placed as a student intern. You are not legally required to provide this information to the HERS Department. However, refusal to provide the information requested could mean that a facility may refuse to accept you at its site. The HERS Department does not guarantee an alternative placement. I hereby authorize the Department of Health, Exercise & Rehabilitative Sciences to release my health information to any facility to which I am assigned during my HERS education, should the facility request the information. This authorization is valid for one year from the date on my background study clearance. __________________________________________________Student’s Name (please print) __________________________________________________Student’s Signature ________________Date MnSCU015 Revised 10/2010

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MINNESOTA DEPARTMENT OF HUMAN SERVICES

Background Study Form Information

PLEASE PRINT CLEARLY!!!!

________________________________________________________________________ First Name Middle Name Last Name ________________________________________________________________________ Date of Birth (mm/dd/yyyy) Gender (M or F) MN Driver’s License # (if applicable) Ethnicity: Asian Pacific Islander African American

Native American Caucasian Hispanic/Latino Two or More Races Unknown/Other ________ (initial) I understand and agree that the College of Nursing and Health Sciences may use my social security number which is located in the student record system for the purposes of completing the back ground check only. ________________________________________________ Phone # (including area code) Home Address: ________________________________________________________________________ City: ____________________________________ State: _________________ Zip: ____________ ______________________________________________________________________________________ Other First Names you have used ______________________________________________________________________________________ Other Last Names you have used _________________________________________________ _________________________________ Email Address Warrior ID # _________________________________________________ Signature Date

Indicate your classification: _____AT major _____ERCR major _____ERES major _____ERMS major _____Public Health major _____Health Promotion-Teaching major _____Faculty – HERS Dept.

Return to: Winona State University Health, Exercise & Rehabilitative Sciences PO Box 5838 – 351 Maxwell Hall Winona, MN 55987 Or fax: 507.457.2554

WINONA STATE UNIVERSITY Department of Health, Exercise & Rehabilitative Sciences

AUTHORIZATION FOR THE RELEASE

OF STUDENT BACKGROUND STUDY INFORMATION To Whom It May Concern:

I, _____________________________________________________________________, hereby

authorize Winona State University located at:

Health, Exercise & Rehabilitative Sciences Department College of Nursing & Health Sciences PO Box 5838 – 351 Maxwell Hall Winona MN 55987-5838 Office 507.457.2600; Fax 507.457.2554 to release information contained in its files (including, but not limited to reports, records and letters or copies thereof) regarding a background study performed by the Department of Human Services, or a request to the Commissioner of Health for reconsideration of a disqualification, to determine my eligibility to participate in practicum and/or internship placements to fulfill the requirements of the HERS programs at Winona State University. This information may be released to the following facilities:

Any organization/site affiliated with Winona State University’s Department of Health, Exercise, & Rehabilitative Sciences

I understand that the University will review this information to assess whether I may be permitted to participate in an educational experience outside the university, such as practicum or internship placements, or any other community program experiences through the Health, Exercise & Rehabilitative Sciences Department. I understand that I am not legally obligated to provide this information. If I do provide it, the data will be considered private education data under state and federal law, and released only in accordance with those laws, or with my consent. I provide this information voluntarily and understand that I may revoke this consent at any time. A photocopy of this authorization may be used in the same manner and with the same effect as the original documents. This authorization expires one year from the date on my background study clearance. _____________________________ Today’s Date ______________________________________________________________________________ Signature ______________________________________________________________________________ Address City State Zip Code

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WINONA STATE UNIVERSITY HEALTH INFORMATION AND REQUIREMENTS FOR PARTICIPATION IN THE

DEPARTMENT OF HEALTH, EXERCISE & REHABILITATIVE SCIENCES INTERNSHIP & PRACTICUM PROGRAMS STUDENT NAME: _____________________________________________________________________________ NOTE: You will NOT be allowed in practicums or internships without the required supporting documentation! If you have questions about any of this information, please contact the Health, Exercise & Rehabilitative Sciences Department. ________ Date & results of mantoux (tuberculin skin) test. Mantoux tests are required yearly. ________ Copy of immunization records from healthcare provider. (Diphtheria-Tetanus;

Measles, Mumps, & Rubella [MMR]; Polio; Hepatitis B) ________ Proof of medical/health insurance. (copy of insurance card)

All practicum/internship students must be covered by health insurance: your own policy, that of your parents or through Medical Assistance. Minnesota State Colleges and Universities (MnSCU) has decided to no longer offer health insurance for domestic students for the 2014-2015 academic year. There are two Minnesota Health Care Programs MnSCU students may qualify for due to their income status, they are Medical Assistance (MA) or MinnesotaCare. Students currently enrolled in Medical Assistance or MinnesotaCare programs will automatically be moved to MNsure as part of their renewal process. If a student is not currently enrolled in one of these programs and would like to know if they qualify for either of them, their eligibility status will automatically be reviewed when they apply for coverage through MNsure. Additional information regarding Medical Assistance or MinnesotaCare can be found on health insurance marketplace MNsure https://www.mnsure.org/

________ Complete MN Background Study form ________ Complete Important Notices form ________ Proof of current First Aid certification (copy of card) ________ Proof of current Adult CPR/AED certification (copy of card)

[CR majors: Basic Life Support for Healthcare Providers or CPR/AED for the Professional Rescuer]

PROFESSIONAL LIABILITY INSURANCE All students in practicum or internships will be billed by Winona State University yearly for professional liability insurance coverage. The policy is an occurrence-based professional liability insurance with $2,000,000/$5,000,000 limits of coverage. No proof of liability insurance coverage is required from you at this time. Student will also be responsible for completing additional site-specific requirements and documentation, as requested. The information provided to the HERS Department for my practicum or internship is accurate, current & complete. Any falsification of this information is sufficient cause for dismissal from the Health, Exercise & Rehabilitative Sciences Major. ___________________________________________________________________________________________ Student Signature Date

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HEPATITIS B VACCINE DECLINATION

Name: _______________________________________________________________ Tech ID Number________________________________________________________ I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B (HBV) infection. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. I accept all responsibility for the consequences of my decision to decline. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series. I also understand that I will bear the expense of the series of vaccine injections and will notify and submit documentation to the HERS office that the series has been completed. Signature: ________________________________ Date: _________________

(Revised 1/23/03)

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CPR/AED & FIRST AID CERTIFICATIONS Student interns must be certified in CPR for ADULT resuscitation. This certification is available from the American Heart Association (Healthcare Provider Course) or the Red Cross (CPR for the Professional Rescuer Course). You are responsible for keeping track of your CPR expiration date; and you are responsible for getting re-certified in CPR if the expiration date occurs prior to the end of the internship period. In addition, Standard First Aid certification must be current. CPR and Standard First Aid certifications MUST be current throughout the period of the internship. You will need to submit photocopies (front and back) of CPR/AED and First Aid cards, indicating date issued, expiration date, and instructor's signature.

Cardiopulmonary Rehabilitation Required Certification

Certifying Agency Course Requirement

1. Basic Life Support for

Health Care Providers Or CPR/AED for the Professional Rescuer

AND 2. Standard First Aid

American Heart

Or

American Red Cross

(On-line certification will NOT be accepted!)

HERS 361 CR Practicum * A front/back photocopy of Certification cards MUST be presented PRIOR to registering. * Certification MUST last thru entire semester or practicum experience.

Community Health Required Certification

Certifying Agency Course Requirement

1. Adult CPR and AED

AND

2. Standard First Aid

American Heart

Or

American Red Cross

(On-line certification will NOT be accepted!)

HERS 350 Program Planning And HERS 395 CH Practicum * A front/back photocopy of Certification cards MUST be presented PRIOR to registering. * Certification MUST last thru entire semester or practicum experience.

Exercise Science Required Certification

Certifying Agency Course Requirement

1. Adult CPR and AED

AND

2. Standard First Aid

American Heart

Or

American Red Cross

(On-line certification will NOT be accepted!)

HERS 363 ES Practicum * A front/back photocopy of Certification cards MUST be presented PRIOR to registering. * Certification MUST last thru entire semester or practicum experience.

21

WINONA STATE UNIVERSITY - REDUCED STUDENT FEE AUTHORIZATION

TO BE COMPLETED BY STUDENT OR DEPARTMENT ADVISOR/INSTRUCTOR____________________ 2 0 1 __ Semester OR Year Term (Summer, Fall, Spring) (1, 3, 5) ____________________________ _________________________ __ __ __ __ __ __ Student’s Last Name Student’s First Name Warrior ID # _____ 0 0 __ __ __ __ __ __ __ __ __ __ __ __ ____________________ ____________________ Cr Hr Course ID# Subj Nbr Course Name Course Site (City/State) _____ 0 0 __ __ __ __ __ __ __ __ __ __ __ __ ____________________ ____________________ Cr Hr Course ID# Subj Nbr Course Name Course Site (City/State) _____ 0 0 __ __ __ __ __ __ __ __ __ __ __ __ ____________________ ____________________ Cr Hr Course ID# Subj Nbr Course Name Course Site (City/State) PLEASE NOTE Reduced student fees include the Union Facility Fee, Wellness Fee, Student Life Fee, Athletics Fee & Health Service Fee ONLY. These fees will be reduced in half, if the course(s) qualify. All other fees at Winona State University are not reduced. Qualification requires that the course(s) be completed beyond the 50 mile radius from the Winona campus. REDUCED FEES DO NOT APPLY TO ONLINE COURSES OR IF YOU ARE ENROLLED CONCURRENTLY IN A WINONA OR ROCHESTER CAMPUS COURSE.

Please submit form to: WSU Department Advisor/Instructor

TO BE COMPLETED BY DEPARTMENT ADVISOR/INSTRUCTOR

This student is scheduled for the entire term at a location outside a 50 mile radius from the Winona State University campus and is engaged in the following activity: (check one)

_____ INTERNSHIP _____ STUDENT TEACHING _____ INDEPENDENT STUDY _____ MEDICAL TECHNOLOGY _____ OTHER __________________ (Please specify) _____________________________ ______________________________________ WSU Advisor/Instructor’s Signature Department Date

Please return form to: Student Accounts, 225 Maxwell

Student Accounts/Accounts Receivable Office Use Only 201___ #_______ $____________ Term Cr Hr Total Waived 9157 FACILITY USE FEE _____________ 9190 WELLNESS CTR FEE _____________

9156 STUDENT LIFE FEE _____________ 9172 ATHLETICS FEE _____________ 9163 HEALTH SVC FEE _____________ DATE ___________ BY __________

REV 04/21/09

22

Health, Exercise and Rehabilitative Science Department Internship WEEKLY WORK LOG & REFLECTIVE JOURNAL (Please follow this format.)

NAME:____________________________________________ SITE:____________________________________________ I. Hours Worked

SHIFT HOURS Monday 7:30 – 5:00 8 Tuesday 8:00 – 5:00 8 Wednesday 8:00 – 5:00 8 Thursday 8:00 – 5:00 8 Friday 8:00 – 5:00 8 Saturday Sunday TOTAL HOURS 40

II. SEQUENCE OF EVENTS Make a brief list describing what happened. By making a list, you keep a record of what happened. This record may be useful for future reference. It allows you to mention all events, even those that seemed insignificant at the time. For example:

Monday Mayo Orientation – Mayo Service: You Make the Difference, Employee Policy Information, Mutual Respect/Sexual Harassment, Safety/Infection Control/Employee Health Service/Employee Assistance Program, Activities/Recognition and Recreation Programs/Dan Abraham Healthy Living Center/Children’s R & R; observed staff members. Tuesday Basic review of job at the DAHLC; defibrillator training; observed staff members. Wednesday Cardiovascular equipment troubleshooting; DAHLC database training; observed staff members

Thursday Observed staff members; had discussion with Dr. Morrey about what projects I will be involved with; sat in on Action and Implementation Team Meeting – discussed orientation process and improvements to be made; started absenteeism research – search system for absenteeism rates for current new members Friday Observed staff members; worked on absenteeism research. Saturday Did not work today. Sunday Did not work today

III. ELABORATION OF ONE OR TWO SIGNIFICANT EXPERIENCES OF THE WEEK Select one or two experiences that are significant to you. An experience may be significant because what happened bothers you, excites you, causes you to rethink your initial ideas (i.e., your perspective, goals, or plans), or convinces you that your initial ideas were valid. Therefore, whether the experiences reflect your successes or your failures, they are significant if you learned something important from them. Once you have selected one or two significant experiences, you should describe them in detail. When you describe the experience, try to relive it. Reliving the experience will enable you to provide as much detail as possible. Make certain that you include what people said, what they did, and how they looked.

Topics might include: • new technology, equipment and tools I worked with • new knowledge, skills or related information I gained from this week’s work, • highlights of this week – new/different/interesting experiences, • interesting relations incidents I observed during this week: (example: observation of management techniques/supervisory

styles, communication problems, conflict resolution methods) • meetings, consultations or training sessions I observed and/or participated in during this period.

IV. ANALYSIS OF EXPERIENCE(S) An analysis of experience s includes an interpretation of what feelings and thoughts may have caused the experience to occur, why they were significant, what questions they raise, and what you think you learned from them. Try to figure out what you accomplished; identify problems that emerge and how you plan to follow up. This last point is the most important. You may have learned what does and does not work in this situation. If so, describe what you conclude. But you may also have learned something about your philosophy (your perspective). Does the experience confirm your ideas or force you to reconsider them? If so, what was it about the situation that affected the applicability of the ideas? Perhaps the episode relates to something you read or learned about in this or some other education course. This would be the place to discuss it. Many experiences raise more questions than they answer.

23

Department of Health, Exercise, and Rehabilitative Sciences STUDENT EVALUATION of Internship Supervisor and Site

______________________________________________________________________ Student Intern _________________________ _______________________ ______________ Internship Supervisor Site Semester Instructor/ Site Evaluation 5- Strongly Agree- excellent learning experience 4- Agree- valuable learning experience 3- Disagree- improvement would facilitate my learning 2- Strongly Disagree- great improvement is necessary for student learning to take place 1- Not enough information to comment

SUPERVISOR EVALUATION 1 2 3 4 5 1. Overall, the quality of my internship experience was 2. Overall, I would rate this internship supervisor 3. My internship supervisor let me know what was expected of me 4. My internship supervisor had time for my questions 5. My internship supervisor was approachable 6. My internship supervisor challenged me to think critically 7. My internship supervisor allowed me to make mistakes 8. My internship supervisor is fair and impartial 9. My internship supervisor gave me immediate feedback on my skills and performances

10. My internship supervisor is knowledgeable 11. I would recommend this internship supervisor to another student

SITE EVALUATION 12. Overall, this internship was beneficial to my learning and career development

13. Overall, this internship provided me with a variety of experiences 14. This site was receptive to interns 15. This site had adequate space for learning to take place 16. This site had adequate supplies for learning to take place 17. This site had adequate equipment for learning to take place 18. This site had adequate reference materials available 19. This site had adequate learning experiences available 20. I would recommend this internship site to another student

Comments: 1. What did you like most about this supervisor, experience and site? 2. What did you like least? 3. Suggestions for the future?

24

Winona State University Department of Health, Exercise, and Rehabilitative Sciences

Internship Mid-point Evaluation

CARDIOPULMONARY REHABILITATION Student Name ______________________________________ Semester/Year ___________________

Behaviors Excellent Very Good Average Fair Poor N/A*

Shows initiative……………………………… Demonstrates Team Attitude……………………….. Models Wellness Lifestyle………………………… Respects Organizations policies/procedures…………… Demonstrates sensitivity to diversity………………… Accepts supervision/constructive criticism…………

Skills

Business Communication (oral, phone)……………… Organizes and completes tasks……………………… Motivates clients……………………………………. Written communication………………………………. Presentation abilities…………………………………… Computer literacy……………………………………. Exercise Leadership/Prescriptor……………………. Administration of physical assessments…………… Health counseling with individuals……………………

Knowledge

Understanding Program Components……………… Understanding Documentation……………………… Understanding risk stratification and monitoring……… Understanding Graded Exercise Testing…………… Exercise Prescription and Programming…………… Topics in Patient Education………………………… Applied exercise physiology…………………… Applied electrocardiography…………………………… Applied pharmacology………………………………….. Health care costs/utilization……………………………. Management of emergencies………………………….. Facilities and equipment……………………………….. Please make additional comments on a separate sheet, based on student’s preparation, performance and attitude. In what areas did the intern demonstrate special strengths? In what areas does the intern need additional work? Signature____________________________________ Title ____________________________________ Organization __________________________ Phone ________________________________________ Please Return to: Teresa E. Lee, 358 Maxwell Winona State University Winona, MN 55987-5838 Fax - (507) 457-2554 or email: telee@winona.edu

25

Winona State University Department of Health, Exercise, and Rehabilitative Sciences

Internship Final Evaluation

CARDIOPULMONARY REHABILITATION

Student Name ______________________________________ Semester _________________/Year__________ Internship Location _________________________________Address__________________________________ Person doing evaluation ___________________________________Phone _____________________________ The student named above was an intern under my direction from _______________ to _________________.

Behaviors Excellent Very Good Average Fair Poor N/A* Shows initiative……………………………….. Demonstrates Team Attitude Models Wellness Lifestyle………………… Respects Organizations policies/procedures…… Demonstrates sensitivity to diversity………….. Accepts supervision/constructive criticism…….

Skills

Business Communication (oral, phone)…… Organizes and completes tasks…………… Motivates clients…………………………. Written communication……………………. Presentation abilities……………………. Computer literacy……………………….. Exercise Leadership/Prescriptor…………. Administration of physical assessments……… Health counseling with individuals……………..

Knowledge

Understanding Program Components……… Understanding Documentation………………… Understanding risk stratification and monitoring… Understanding Graded Exercise Testing…… Exercise Prescription and Programming……… Topics in Patient Education……………. Applied exercise physiology…………………. Applied electrocardiography…………………… Applied pharmacology……………………….. Health care costs/utilization……………. Management of emergencies………….. Facilities and equipment…………….. Please make additional comments on a separate sheet, based on student’s preparation, performance and attitude. In what areas did the intern demonstrate special strengths? In what areas does the intern need additional work? Signature _________________________________________ Title_______________________Date ________ Please return to: Winona State University - Teresa E. Lee, Fax - (507) 457-2554 or email: telee@winona.edu

26

Winona State University Department of Health, Exercise, and Rehabilitative Sciences

Internship Mid-point Evaluation

EXERCISE SCIENCE

Student Name: _____________________________________ Semester/Year: _____________________ Internship Location: _________________________________ Address: ____________________________ Person doing evaluation ______________________________ Phone: __________ __________________ The student named above was an intern under my direction from _______________ to ______________. 5=Exceeds Expectations, 4=Often Exceeds Expectations, 3=Regularly Meets Expectations, 2=Sometimes Doesn’t Meet Expectations, 1=Seldom Meets Expectations, NA=Not Applicable. Behaviors 5 4 3 2 1 N/A* Shows initiative…………………………………….. Demonstrates team attitude & functions with team Models wellness lifestyle…………………………… Respects Organization’s policies/procedures……… Demonstrates enthusiasm………………………….. Accepts supervision/constructive criticism…………. Is Punctual with few absences Exhibits ethical behavior Responds calmly & effectively under pressure Skills Business communication (oral, phone)…………….. Organizes and completes tasks…………………….. Motivates clients……………………………………. Written communication……………………………………. Presentation abilities……………………………. Exercise Leadership…………………………………. Administration of health/exercise assessments……… Health/exercise counseling with individuals……….. Exhibits compassion & confidentiality. . . . . . . . . . . Demonstrates problem solving skills. . . . . . . . . . . Knowledge Understanding behavior change…………………….. Topics in health promotion (e.g. nutrition, stress) Functional anatomy………………………………… Applied exercise physiology………………………… Exercise Testing………………………………… Exercise Prescription & Programming………………. Pathophysiology and Risk Factors Exercise Technique…….………………………….. Safety, injury prevention, & emergency procedures Seeks new knowledge………………………………………….. Program administration, quality assurance and outcome assessment

What is the quality of the student’s performance to date (specify both strengths/weaknesses)? How will the student be addressing areas that need improvement? Please make additional comments, based on student’s preparation, performance and attitude, on a separate sheet.

Signature ______________________________________ Title___________________________ Date ________ Please return to: Exercise Science Internship Advisor Winona State University, HERS Department -351 Maxwell, Winona, MN 55987-5838; Fax - (507) 457-2554

27

Winona State University

Department of Health, Exercise, and Rehabilitative Sciences Internship Final Evaluation

EXERCISE SCIENCE

Student Name: _____________________________________ Semester/Year : _____________________ Internship Location: _________________________________ Address: ___________________________ Person doing evaluation ______________________________ Phone: ____________________________ The student named above was an intern under my direction from _______________ to ______________. 5=Exceeds Expectations, 4=Often Exceeds Expectations, 3=Regularly Meets Expectations, 2=Sometimes Doesn’t Meet Expectations, 1=Seldom Meets Expectations, NA=Not Applicable. Behaviors 5 4 3 2 1 N/A* Shows initiative…………………………………….. Demonstrates team attitude & functions with team Models wellness lifestyle…………………………… Respects Organization’s policies/procedures……… Demonstrates enthusiasm………………………….. Accepts supervision/constructive criticism…………. Is Punctual with few absences Exhibits ethical behavior Responds calmly & effectively under pressure Skills Business communication (oral, phone)…………….. Organizes and completes tasks…………………….. Motivates clients……………………………………. Written communication……………………………………. Presentation abilities……………………………. Exercise Leadership…………………………………. Administration of health/exercise assessments……… Health/exercise counseling with individuals……….. Exhibits compassion & confidentiality. . . . . . . . . . . Demonstrates problem solving skills. . . . . . . . . . . Knowledge Understanding behavior change…………………….. Topics in health promotion (e.g. nutrition, stress) Functional anatomy………………………………… Applied exercise physiology………………………… Exercise Testing………………………………… Exercise Prescription & Programming………………. Pathophysiology and Risk Factors Exercise Technique…….………………………….. Safety, injury prevention, & emergency procedures Seeks new knowledge………………………………………….. Program administration, quality assurance and outcome assessment What areas did the intern demonstrate strengths?

In what areas does the intern need additional work? What suggestions for improvement in training of future interns/graduates would you like to make?

Please make additional comments, based on student’s preparation, performance and attitude, on a separate sheet. Signature ______________________________________ Title___________________________ Date ________ Please return to: Exercise Science Internship Advisor Winona State University, HERS Department -351 Maxwell, Winona, MN 55987-5838; Fax - (507) 457-2554

28

Public Health Internship Supervisor’s Evaluation Form Thank you for undertaking this evaluation of your interns’ work. Please award students a grade (1 – 5) for each competency listed in the rubric below. If a competency is not applicable to the internship, please write in ‘N/A.’ Please write any other comments you have about the student in the space below the rubric. If you have a question or comment please contact the internship supervisor whose address is at the end of this form.

Please check one This is the:

Mid-point evaluation Final evaluation Name of Student Date the student’s internship began Name of agency/organization sponsoring the internship Name of supervisor

Competency Very Poor

1 Poor

2 Good

3 Very Good

4 Exemplary

5 Score

Use the code of Ethics in professional practice

Practice is very unprofessional. Behavior is not what you would expect of a professional.

Always respects the rights, dignity and

confidentiality diverse

audiences.

AND

Practice is usually

professional. (occasionally can

behave in a childish or

irresponsible way but changes behavior when this is pointed

out.)

Practice and personal

behavior is always

professional – never needs

advice on how to behave

professionally.

Practice and personal

behavior is always

professional.

AND

All practice respects the dignity and

confidentiality of diverse

populations.

Practice and personal

behavior is always

professional.

AND

All practice respects the dignity and

confidentiality of diverse

populations.

AND

Obviously goes to some length

to remain current and

updated on all professional

issues.

Initiate a plan of action

Does nothing without being told first what to do – ‘a bump on a log.’

Will ask what to do rather than sitting and doing nothing but needs a great

Can initiate a plan of action but requires others to sit down and plan

An excellent and reliable implementation team member but not a leader.

Is able to lead an implementation team. You can trust

29

Competency Very Poor 1

Poor 2

Good 3

Very Good 4

Exemplary 5

Score

Will sit for hours doing nothing if not told what to do.

deal of micro-management and support to keep on task. Lacks initiative and/or confidence.

out the work in some detail. Some lack of initiative and confidence.

them to completely implement a plan.

Apply implementation strategies

Seems unable to follow a plan or strategy – cannot be kept on task.

Sometimes follows plans and strategies, but sometimes seems unable to see what needs to be done.

Is always able to follow implementation plans BUT Cannot see when changes need to made.

Is always able to follow implementation plans AND is able to recognize when changes need to be made to plans or strategies. Will alert you to this but will wait for you to suggest what changes need to be made.

Is always able to follow implementation plans AND is able to recognize when changes need to be made to plans or strategies – will suggest what changes need to be made.

Implement intervention strategies to facilitate health related behavior change.

Seems completely unable or unwilling to work with target audience to promote behavior change.

Is able to give information to target audience regarding behavior change but is not really able to discuss it – seems shy or unconfident.

Gives information to target audience and is able to discuss the information with the target audience.

Is able to discuss target audience’s behavior with them and give out appropriate information and advice regarding change.

Involves the target audience in planning, implementing and evaluating plans and strategies for behavior change.

Develop volunteer opportunities

Never involves or consults

target audience in any

programming work despite

being expected to.

Recruits volunteers to

provide services for

implementation.

Consults target audience about

all plans and interventions. Asks questions

such as: do they like it, do they understand it?

Assigns work to

volunteers.

Works with target audience

to plan, implement and

evaluate the work.

Target audience plays a central

role in all program activities.

Actively recruits AND trains

leaders from target audiences to play a central role in planning,

implementing and evaluating

programs.

Select resource materials for dissemination.

Selects resource material which is not relevant to

program information

needs.

Selects resource material which is relevant but not well designed to meet audience

needs.

Selects resource material which is relevant and well

designed to meet program

objectives.

Selects resource material which is relevant and well

designed to meet program

objectives

Material

Devises a checklist for

material selection and

reviews all available

material before suggesting ordering.

30

Competency Very Poor 1

Poor 2

Good 3

Very Good 4

Exemplary 5

Score

selected is culturally

competent – designed with

the needs/ perspectives of

the target audience.

All material

suggested for use is actually usable in the

program.

AND

Suggests printing own material if

adequate resource

material is not available.

AND

Considers costs and possibilities

of designing/ printing own

material for the program versus

using pre-designed

resources. Establish consultative relationships

Does not see the need for consultation – prefers to ‘go it alone.’

Recognizes the need for consultative relationships but is unable to suggest appropriate organizations or individuals who might be useful to work with.

Suggests organizations and individuals to work with to develop and implement plans. Does not seem to know how to contact these organizations.

Suggests organizations and individuals to work with to develop and implement plans. Will establish contacts. Contacts these organizations but is not always able to maintain a relationship and involve them appropriately.

Suggests organizations and individuals to work with to develop and implement plans. Takes the lead in contacting these organizations/ individuals and involves them in appropriate ways in all stages of planning and implementation.

Respect of working practices

Often late or absent. AND/OR Often inappropriately dressed AND/OR Is sometimes disrespectful.

Late once without prior apology AND/OR Dressed inappropriately once – corrects behavior when asked. Always respectful

Never late or absent without prior apology. Never inappropriately dressed. Always respectful Sometimes is unable to complete tasks on time –

Never late or absent without prior apology Never inappropriately dressed Always respectful Sometimes is unable to complete tasks on time but tells

Never late or absent without prior apology Never inappropriately dressed Always respectful Informs you promptly of any problems concerning

31

Competency Very Poor 1

Poor 2

Good 3

Very Good 4

Exemplary 5

Score

explains this when asked

you that this might be a possibility and negotiates new times.

completion of tasks – can foresee problems and take action to circumvent them before they occur.

Response to constructive criticism

Gets angry and argues – takes the criticism as an insult. Makes no attempt to change behavior.

Is defensive – makes excuses and does not seem to listen. Will change behavior if pushed to do so – requires repetition of criticism before change even contemplated.

Seems to accept criticism but does not always make the changes you agree need to be made.

Always listens to feedback and discusses your criticism in a helpful positive way. Makes the changes that you both agree need to be made.

Always listens to feedback and discusses your criticism in a helpful positive way. Makes the changes that you both agree need to be made. Is able to criticize own behavior and make changes before you suggest them.

Total

Other comments: Supervisor’s Signature Date this form was completed Thank you for completing this form. Please send, fax or email completed forms to:

Dr. Peter Sternberg psternberg@winona.edu Department of Health, Exercise and Rehabilitative Sciences Winona State University PO Box 5838 Winona, MN 55987 Tel: (507) 457-5693 Fax: (507) 457-2554